test form Section 1. About you Note: Questions marked by * are mandatory This form helps us understand you better so we can provide safe, personalised care during your pregnancy. Some questions may feel personal, but your answers are confidential and only seen by staff involved in your care. You'll also have a chance to speak privately with a midwife at your first appointment. Note: “You” or “your” refers to the woman or birthing person who is currently pregnant. *This is a mandatory field. 1. Are you completing this form for: Yourself Someone else 2. If you selected "someone else", please tell us your relationship to the woman/birthing person. *This is a mandatory field. 3. Your first name *This is a mandatory field. 4. Your surname or family name *This is a mandatory field. 5. Please tell us if you have used any previous names. If not, please write "none." *This is a mandatory field. 6. Your preferred pronouns She/Her/Hers He/Him/His They/Them/Theirs Other Prefer not to say right now *This is a mandatory field. 7. Your date of birth *This is a mandatory field. 8. Your home address *This is a mandatory field. 9. Your telephone number ((If you do not have a mobile number, please provide another numberwhere we can reach you) *This is a mandatory field. 10. Email (if you do not have an email address please enter email@example.com) 11. If you have or know your NHS number, please include it. If not, you can leave this blank. You can find your NHS number here: https://www.nhs.uk/nhs-services/online-services/findnhs-number/ 12. I do not have an NHS number None 13. Who is your next of kin or emergency contact? (We'll only use this if we cannot reach youand there is an urgent concern about your health). 14. What is their relationship to you? 15. What is their contact number? 16. Are you currently a UK resident? Yes No Don't know 17. If you answered no to question 17, how long have you lived in the UK? We ask this tounderstand who is entitled to free hospital care or who might be charged under thegovernment's regulations. This does not affect your right to receive maternity care. Under 12 months 12 months or more 18. If you answered no to question 16, what is your main reason for stay: Work Study Joining family Visiting Seeking asylum Other 19. If other, please explain. 20. Do you have an EHIC/GHIC, S1/S2, or other reciprocal healthcare cover? This helps us bill thecorrect organisation where applicable. Yes No Don't know 21. Which best describes your current status? This helps us apply the correct NHS rules andconnect you to any support you're entitled to. Your care will not be delayed while we checkthis. I am a refugee (granted status) I am seeking asylum My asylum application was refused None of the above/prefer not to say *This is a mandatory field. 22. Are you a member of the Armed Forces Community? Yes No Don't know *This is a mandatory field. 23. Are you registered with a General Practice/Family Doctor? Yes No *This is a mandatory field. 24. If yes, please provide the name and address of your GP practice. *This is a mandatory field. 25. Do you have a preferred hospital or place of birth? Newham Hospital (Newham) The Royal London Hospital (Tower Hamlets) Whipps Cross Hospital (Waltham Forest) 26. Are you interested in a home birth? Yes No Don't know *This is a mandatory field. 27. Have you had care for this pregnancy from a doctor or midwife at another hospital or in another country? Yes No Don't know 28. If yes, please tell us where you received care for this pregnancy (for example, the name ofthe hospital or clinic and the country). Ethnicity, language and additional needs of the woman/birthing person Why do we ask about your ethnicity during pregnancy? Some health conditions and pregnancy risks can affect ethnic groups differently. *This is a mandatory field. 29. What is your ethnic background? Asian - Any Other Asian Background Asian or Asian British - Bangladeshi Asian or Asian British - Indian Asian or Asian British - Pakistani Black - Any Other Black Background Black or Black British - African Black or Black British - Caribbean Mixed - Any Other Mixed Background Mixed - White and Asian Mixed - White and Black African Mixed - White and Black Caribbean White - Any Other White Background White - British White - Irish Other - Chinese Other - Any Other Ethnic Group Other - Not Stated 30. If other, what is your ethnic group? *This is a mandatory field. 31. Do you need an interpreter or British Sign Language (BSL) support? We want to make sure that we can communicate with you clearly. Friends and family members cannot act as interpreters. If you would like an interpreter, we can provide this service at no cost to you. Yes No Don't know 32. If yes, what language? (If you require BSL support, enter "BSL"). 33. Is there anything we can do to help you take part in your appointment? This could include: how you prefer to communicate, cultural or religious considerations, support for learning disabilities or neurodiversity, help with physical or sensory disabilities, any other adjustments you may need. Proceed Summary You are here: Page 1 of 4
